University of Cincinnati DPT - Systematic Clinical Reasoning Worksheet

PATIENT PROFILE
Lynne is a 52 y/o hispanic female who is complaining of shoulder pain.
Chief Complaint: Right shoulder ache at the end of the day that is making quilting and gardening more
difficult
Work: she works in sales at an office supply company. Primarily desk job.
Work restrictions: none
Current exercise or activity level: None. Sits at desk during the day. After work she either watches TV or
works on sewing
Previous activity level: same

PATIENT-CENTERED HISTORY
Area and behavior of symptoms:
P1 – Right shoulder. Deep. Intermittent, variable. Ache, sore, occasionally sharp. 0-7/10
P2 – Central cervicothoracic junction. Intermittent, variable. Tight, sore, ache. 0-4/10
Relationships between areas of symptoms: P1 can be present without P2, but when P2 is present, P1
tends to be worse.
Aggravating factors or currently performed activities that provoke areas of symptoms:
P1: reaching overhead to brush/wash her hair brings on symptoms after about 30 seconds and usually
takes 30 minutes to ease. Increased soreness with prolonged sewing especially if she is having to reach
forward to complete project. Eases after 30-60 minutes. Increased soreness and occasionally sharp
reaching behind her back to fasten bra, eases after 30 minutes. Pain with gardening – anything that
requires her to lift or reach overhead. Progressive soreness during the work, then takes several hours to
ease and will sometimes keep her up at night.
P2: usually notices increase in back/neck pain if she spends several hours at her desk, tends to be most
noticeable toward the end of the week. Once it comes on, it usually takes a few hours to settle down if not
overnight.
Easing factors or activities that ease areas of symptoms:
P1: shoulder seems to feel better with easy movement, walking around a bit or just swinging her arm.
Ibuprofen helps, but she only takes this on the weekends after she has been working in her garden. She
has learned to avoid those activities that tend to bother her more.
P2: frequent breaks from her desk, walking around the house or in the yard.
24 Hour Behavior of Symptoms:
P1 – shoulder is stiff for 5-10 minutes in AM then eases with morning activities. Usually sore by the end of
the workday and achy when she goes to bed at night. No night pain, unless she has been more active
during the day or if she sleeps on her right side.
P2: usually only sore at the end of the workday. No AM or night pain.
History of Present Episode: her shoulder really started being an issue about 2 months ago. No specific
injury. Because she has been working at home for the last 12 months, she decided to spend more time in
her yard. She and her husband spent the summer cleaning up her yard – trimming a lot of trees,
gardening, weeding and building a fence. This was a pretty dramatic increase in activity for her. They
started in May and by early August her shoulder started getting sore. She had to stop working in the yard
in the last few weeks because it hurts too bad and it is now interfering with her sleep. With the decreased
work in the yard, the pain has improved because she isn’t doing as much, but still really painful with her
aggravating activities.
Went to see her PCM about a month ago. Prescribed ibuprofen and sent for an MRI – pending
scheduling. Then referred to PT. Ibuprofen helps with the soreness when she takes it – 3-4 times per
week.
History of Previous Episodes: She does recall having some shoulder pain about 15 years ago when
she was playing in a summer volleyball league. Pain resolved after she stopped playing. No previous
shoulder injuries. Neck/upper back pain has been an on/off issue for 20+ years. Typically, only an issue
with prolonged sitting at her desk. No treatment to date – really never been more than a minor issue. She
thinks her neck pain has been slightly better over the last few months – since working at home she tends
to spend less time at her desk.
Patient Goal: Improve shoulder pain with ADLs, sewing and eventually with return to gardening.
Other info: Transportation is an issue for her – her car needs repairs, and she is unable to afford the cost
of fixing it. She also relates increased stress/anxiety due to family issues and financial insecurity

PHYSICAL EXAMINATION
Outcome measure: SPADI, DASH, QuickDASH all would be appropriate here. OSPRO-YF
Resting symptoms: P1: 4/10 sore after getting dressed and washing/brushing her hair this AM. P2: 0/10
Demonstration of symptom or functional limitation producing activity: shoulder pain is reproduced
to 7/10 by reaching up to her head to demonstrate washing her hair – eased back to 4/10 for a few
minutes once done.
Observation: limited use of right arm during the interview. Guarded with all right arm motions and during
gait.
Neurological exam: Bilateral upper extremity biceps/brachioradialis/triceps MSR 2+ symmetrical.
Sensation intact to light touch bilateral upper extremities. Negative Hoffmann’s. No ataxic gait.
Range of Motion: Active motion: Right shoulder flexion with increase in pain starting at 45 degrees,
increases to 100 degrees, then stops due to pain. Right shoulder abduction with increase in pain at 30
degrees, increases to 75 degrees, then stops due to pain. Right shoulder IR with arm at side – hand to
abdomen. Unable to measure at 90 degrees due to pain and unable to reach behind back due to pain.
Right shoulder ER with arm at side – to 20 degrees from neutral, sore with no meaningful increase in
symptoms
Passive motion: Flexion to 140 before onset of pain. Other motions deferred due to progressive increase
in pain.
Strength: isometric strength testing with arm at side – flexion 4/5, abduction 4/5, IR 4/5, ER 4/5, all with
pain
Joints cleared: Cervical motion – demonstrates full active motion in all directions. Left rotation sore at
end range and increased local pain with overpressure. No change in shoulder pain with any cervical
motions.
Special diagnostic tests: deferred
Palpation Findings: diffuse tenderness over posterior and lateral shoulder.
Passive Movement Assessment: Caudal glide at glenohumeral joint to IV- with improvement in
symptoms
Response to exam: 5/10, slightly more stirred up.

Patient Profile
Age: 52 year old
Gender: Female
Occupation: Sales at an office supply company (desk job)
Hobbies: quilting and gardening

Chief Complaint (why are they coming to physical therapy): Right shoulder ache at the end of the day that is making
gardening and quilting difficult
Part 1: ASSESSMENT OF THE BODY CHART: what areas/structures must be considered as possible sources of
the patient’s symptoms? Consider the following:

Joints & Muscles & Ligaments, MSK Pain NON-MSK

bony Tendons, Nerves and producing structures or
structures UNDER & IN other Soft structures conditions
UNDER THE the area of Tissues which may which must
AREA of symptoms UNDER & IN REFER into be examined
symptoms the area of the area of or ruled out
symptoms symptoms

GH joint Supraspina GH Rotarcuff Liver

AC joint tus ligaments muscles Gallbladder
Infraspinat AC and Lung
Acromion us ligaments tendons Heart
Humerus Subscapul Labrum GH joint
Glenoid aris Axillary AC joint
fossa Teres nerve AC ligt.
clavicle minor Coracoclav CC. ligt.
Biceps icular Cervical
Brachii ligament spine
Pec major UT and LS
Pec minor muscles
Deltoid CT
Teres junction
major
Latissimus
dorsi
Upper trap
Rotator
cuff

Initial Hypotheses

Most Likely Hypothesis: Less Likely Hypothesis: Remote Hypotheses:

(Primary Hypotheses) (Secondary Hypotheses) (Include at least 1 hypothesis
requiring referral)

1. Subacromial impingement 1. Rotator cuff tear 1. OA

2. Rotator cuff tendinopathy 2. Scapular dyskinesis 2. Lung cancer

Planning the Interview: What questions will you ask to clarify or gather information to support/refute each hypothesis?

In the last two weeks, have you
noticed little interest or pleasure in
doing things?
In the last two weeks have you
experienced feelings of being
down, depressed, or hopless?
What activity causes the most
shoulder pain?
How have you modified your
activities? Have you found any
success? If not, what still bothers
you?
Have you had any N/T in your
shoulder? If so, does it radiate
down your arm?
When you have your night pain,
what activities do you do during
the day? Are you able to go back
to sleep?
How have you managed your back
pain over the last 20 years? Is this
pain the same or different than
what you have felt in the past?
 Have you had any problems with
gripping

What activities increase your

neck/back pain besides sitting?
How do you sit at your desk? Have
you found any positions to help?

Part 2: Revised and Reprioritized Hypotheses/Planning the Physical Exam

Most Likely Hypothesis: Less Likely Hypothesis: Remote Hypotheses:

(Primary Hypotheses) (Secondary Hypotheses) (Include at least 1 hypothesis
requiring referral)

1. 1. 1.

2. 2. 2.

Determine the patient’s SINSS - consider how that will influence your exam and treatment

Severity Irritability Nature Stage Stability

High High MSK Acute Getting better
Mod Mod Non-MSK Subacute Getting worse
Min Min Psychosocial concerns Chronic Staying the same

☐ ☐ ☐ ☐
- Highly limited exam due to - Moderately limited exam due - Minimally limited exam due to - Unlimited exam due to
anticipated tolerance to anticipated tolerance anticipated tolerance anticipated tolerance
- ROM 1st onset of sx - ROM to active limit - ROM to passive limit - ROM to sustained/ combined
- Very low vigor and extent - Low vigor and extent of - Moderate vigor and extent of - High vigor and extent of
of tests/measures tests/measures tests/measures tests/measures

Rationale: I would say that she is somewhere in the moderately limited. She is able to do some activity with limited pain.
The only thing that really causes her sharp pain is reaching behind her back and prolonged/progressive overhead
activities really flares her up. I would be cautious and stay as pain and symptom free as possible, but I wouldn’t have a
problem bringing on a little bit of symptoms if I felt it was necessary. Her high stress and anxiety is something to keep in
mind especially with vigor of the exam.

Part 3: Planning the Physical Exam

What movement/functional test is most related to their chief complaint? Reaching overhead

Physical Exam Plan for day #1: Prioritize based on the most likely or most concerning hypothesis and the patient’s
tolerance to the exam. List in order of importance.

Prioritized P/E tests and measures: Justification:

Observation/Palpation: An exam should always start off with some version of

 Anterior, lateral, and posterior shoulder observation and palpation. I would look to see how this
musculature person moves their shoulder when they walk and how they
  Periscapular and cervical spine/neck musculature
 Watch her reach overhead and out infront, walk,
seated and standing posture
Neuro and cervical screen
 Dermatomes, myotomes, gross cervical ROM w/
overpressure, cervical distraction and
compression
o If she is having neck pain refer into the
shoulder we are thinking lower cervical
referral into the trap/lateral shoulder and
scapula
AROM/PROM:
 Shoulder flexion, ABD., IR, and ER (short of
symptoms)
MMT:
 Shoulder flexion, ABD., IR, and ER

position themselves when they sit. This will allow us to see
any guarding or compensations. You would then palpate
the structures of the shoulder and scapula to “feel and
reveal” any tissue/structures abnormalities and identify
anything that is TTP. This can allow you to further identify
or confirm tissue and structure involvement. Neuro screen
allows you to rule out or in any neurological
involvement/impairment. The cervical screen allows you to
take a quick look at motion in their cervical spine and
gives you an idea if the primary issue is actually the c-
spine referring to the shoulder. AROM in those directions
should be done just short of symptoms since we don’t
want to flare her up. She is having problems with reaching
overhead and behind her back which is why I chose those
directions. It would be important to quantify her shoulder
strength to see if it weakness that is causing shoulder pain
or some other issue. Grip strength should not be
aggravating to her since she doesn’t have any complaints
with holding things. There have been a few studies that
have looked at grip strength and how it correlates to the
shoulder and rotator cuff.

Exam items deferred to future visits (list in priority)

Prioritized P/E tests and measures: Justification:

AROM: extension At the moment, the patients symptoms are elevated and
MMT: extension, serratus anterior, LT, UT, MT, rhomboids easily aggravated and I suspect she wont be able to
Apley’s scratch tolerate a truly comprehensive examination. Strength
Lift and Carry testing of the periscapular muscles isn’t a day one priority
Grip strength assesment and also puts the shoulder in a lot of awkward positions
Cervical/Thoracic PA’s and side glides that will likely cause pain. Apley’s scratch would not be
Thoracic mobility tolerated and similar to her reaching behind her back
which brings on an immediate increase in symptoms, but it
would be helpful at some point to quantify her ability to
reach back and mimic fastening her bra. Grip strength
may good to examine but isn’t as important day one.
Cervical and thoracic issues are secondary to her
shoulder pain so it isnt a day one priority, but we would
want to address these areas to see if there are any
contributions to the current shoulder problem.

Part 4: Assessment

Is the patient an appropriate candidate for physical If refer, indicate reason to include what and why (imaging,
therapy intervention? lab, specialty, etc.):

N/A
☐Treat ☐Treat and Refer ☐ Refer

Most important baseline findings from the interview: Overhead activities is painful, neck/back pain comes on
after sitting at desk for hours, movement of the shoulder especially with walking is an easing factor,
psychosocial concerns including transportation, family issues, financial instability, depression, and anxiety.
Activity Limitation or Participation Restriction (list in order of importance)

1. Unable to perform gardening work involving reaching overhead and carrying objects

2. Sewing is difficult to perform for prolonged periods of time especially once she has to reach forward when
sewing.

3. Reaching overhead for longer than 30 seconds is painful

4. Reaching behind her back to put on her bra immediately brings on sharp pain in the shoulder

5. Sitting at her desk for greater than 2 hours begins to bring on her neck and back pain

Most important baseline findings from the examination:

Impairment/movement test What limits (pain, stiffness, strength, What aggravating factor is this related
(order of importance) control, etc.) to?

1. Reaching overhead 1. pain 1. Her ability to wash and brush

her hair
2. Flexion
2. pain
2. Reaching overhead,
3. IR wash/brush her hair,
3. pain gardening

4. Strength
4. pain 3. Reaching behind her back to
fasten bra and wash/brush
the back of her head.

4. Ability to perform gardening

activities

Most Likely Hypothesis: Alternate Hypotheses:

RTC Tendinosis Subacromial impingement.

What clinical evidence supports this? What clinical evidence supports this?

She had a previous history of shoulder pain when playing
volleyball that may have been rotator cuff related. We
know that their may be some degenerative changes with
the RTC tendons that happens with age and use of the
shoulder. This is likely not an acute inflammatory issue but
a progressive shoulder issue that was further exacerbated
by an increase in activity and load that was not normal to
the patient prior to this injury. She has issues with
prolonged activities like sewing for long periods of time or
holding her arms up above her head in order to
brush/wash her hair. I would expect her ROM and strength
to be even more limited for me to be suspicious of serious
rotator cuff tears.
She is limited in both her AROM and PROM as well as
strength due to pain. She recently had an increase in
activity and load through her shoulder that started to
cause her shoulder pain. Not using the shoulder to
perform overhead activities has helped which is a good
sign. The increase in load and activity may have resulted
in altered biomechanics especially as she goes overhead
causing inflammation to the RTC and causing the tendons
to further hit up against the acromion.
Part 5: Prognosis

What is the natural history of this disorder? How do you expect it to progress over time?

She had an episode of shoulder pain 15 years ago while playing volleyball that was relieved by not playing volleyball.
She had a recent increase in overhead activity and load through the shoulder that has now flared the shoulder pain and
symptoms up. She kept this pace of activity up over a couple month period which further caused her pain to get worse
and further limited her in her abilities to garden and sow. This paints the picture of a rotator cuff tendinosis injury. I
would expect that if she were to keep up her current level of activity that things would get progressively worse and she
would ultimately end up causing partial or full-thickness tears in her rotator cuff. With therapy, I would expect a slow
healing time of 3 months or more. She has a lot of psychosocial factors that will effect her healing and may cause this
to take more time than what we typically see with rotator cuff related pathology. The early focus would be symptom
reduction and getting things calmed down and under control. Once she is able to calm things down, we would introduce
more motion and strengthening for the shoulder to get her confident in moving and using. We would want to modify
activities and give her ways to manage and control symptoms when she experiences flare ups. Ultimately, if she
adheres to physical therapy I would expect a full return to normal ADL’s/

Likelihood of recurrence: MILD / MODERATE / HIGH

How will you attempt to prevent recurrence of symptoms?
Provide her with proper education on prognosis of her injury and give her appropriate exercises that will allow her to
manage her symptoms when flare ups occur. This would be a mix of exercises as well as other stress relieving activities
that can hopefully get her calmed down and in control of her symptoms.

Contextual Factors: What contributing factors will influence this patient’s prognosis? Depression, anxiety,
transportation issues, financial instability, family issues

Personal Factors: How will you account/address these?

(Health/wellness, psychosocial, efficacy, age, gender, etc.)
1. Depression and anxiety
2. Transportation/Financial instability
3. Age
. resources to help her manage her personal struggles.
As mentioned, multiple times above, we know that
degenerative changes can just naturally occur to our
shoulders and RTC’s. Educating her that we expect things
to get better but that we won’t cure her from forever having
shoulder pain again will be important. Education on
prognosis and a good HEP can help her long-term
manage this issue. Diaphragmatic breathing and
meditation can help. We also are in the place to give her
Since she does have some transportation/financial issues
I would see her less often. I might start out at 2 times a
week for a week or two and then transition her to a once a
week or once every other week.

Environmental Factors: How will you account/address these?

(Occupation, location, home/family, cultural, etc.)
With this patient I think her working at home is a good
1. Desk job/work from home thing. This will allow us to encourage her to get up and
walk often, especially if it makes her shoulder feel better. I
think this also allows us to give her some stuff to do in the
2. Family issues middle of the day since she doesn’t have to worry about
being in other people’s way or having people watch her. I
would probably ask if she would like to speak to a social
3. worker to see if they couldn’t help. Some clinics have
social work on hand so it may work out where she can see
you for therapy and the LSW one right after another.

SMART GOALS: Specific, Measurable, Attainable, Realistic, and Time-Oriented

What is the patient’s goal?

Improve shoulder pain with ADLs, sewing and eventually with return to gardening.
Short Term Goals Long Term Goals
1. Patient will demonstrate pain free 4/5 MMT of her 1. Pt. will demonstrate Right pain-free Shoulder
right shoulder in the next 3 weeks AROM that is equal to her left so she can
brush/wash her hair pain free in the next 8 weeks.

2. Patient will report resting pain < 2/10 in the next 3

weeks. 2. Pt. will be able to fasten her bra pain free in the
next 8 weeks.

Justification/ relationship to long term goals and chief Justification / relationship to the chief complaint and
complaint: patient’s goals:

Patient wants to decrease overall pain so she is able to
improve her ADL’s, gardening, and sowing. Reducing pain
is specifically stated in her goal and we need to decrease
pain before we get aggressive with ROM and
strengthening.
Patient complains of her inability to wash or brush her hair
for more than 30 seconds without pain and soreness
following. Working on her ability to go over head pain free
will help with this as well as her ability to reach overhead
when gardening and doing other activities. She also gets
an immediate and sharp pain when reaching behind her
back that makes it difficult to fasten her bra. Her
symptoms then linger for a while following one of her
movements.

Part 6: Plan of Care

How many visits over what period of time do you expect to see this patient? Why?

I would start her out twice a week for the first week or two in order to really get things calmed down, educate her, and
start building a really good HEP so she doesn’t have to come as frequently. She has transportation issues as well as
some financial and family burden that may cause some additional stress and issues with coming in to the clinic. She
should do fine with a HEP that can be further progressed and improved as she progresses when she comes to the
clinic. After the first week or two I would look at seeing her once a week for two weeks and then move to every other
week once I know she is able to adhere to her HEP, understands how to manage her problem, and is progressing
appropriately

What patient education will you provide (at a minimum include diagnosis, prognosis, plan [both what you will do and
what they will do]):

Diagnosis/Assessment: Based on our interview and exam findings it seems your pain is coming from a group of
muscles in our shoulder called the rotator cuff muscles. They are four muscles that help move our arm overhead
correctly and help keep our shoulder in positions for long periods of time. You may have had an injury to these muscles
15 years ago which has been reaggravated with your recent increase in load and activity. These muscles are commonly
flared up and injured in the general population and it is not uncommon for people to experience sort of the same things
you are having issues with. You have done a lot over the past couple months so these muscles are a little irritated and
angry with you.

Prognosis (what does their recovery look like?):

Right now, what we need to do is get your symptoms calmed down and make some modifications to some of the
activities you are doing in your day to day life that way your muscles aren’t so angry with you. We can do this through
some gentle motion and strengthening that will help reduce some of your pain and symptoms and hopefully make your
shoulder feel better. Once it has calmed down and feeling better we will begin to add more motion and strengthening
activities to get those muscles comfortable with moving again as well as getting them strong so they are able to move
more and tolerate more activity. Then we will begin to work on activities like reaching overhead, out in front of you, and
behind your back to allow you to do these activities with more confidence and less pain. I expect you to be able to get
back to do everything you love to do, but I can’t cure your shoulder pain and guarantee you that you will never have
shoulder pain again. What I can do is get you back to those activities with as little symptoms as possible as well as
equip you with the necessary information, exercises, and resources so you can manage your shoulder pain and be in
control on your shoulder pain.
Plan of care
- PT plan (what you add):
Diaphragmatic breathing, meditation, AAROM: dowel rod, pulleys, finger walking, wall slides, wall washes, IR
with belt, pendulums; shoulder strengthening exercises: isometrics pain free throughout their available range,
overhead presses, front raises, elevated surface pushups/push up pluses, lift and carry, resistance bands
(flexion, extension, IR, ER, ABD.); walking program, sled pushes; thoracic mobility: ext. over chair, over half
foam roll, open books; Scapular strengthening: I’s, Y’s, T’s, rows, pull downs,

- Patient plan (what they can do):

- Adhere to HEP, complete walking program and continue to incorporate movement and activity in life, be able to
modify activities that cause symptoms to come on, practice meditation and diaphragmatic breathing that allows
them to calm down body when they are feeling anxious, participate in activities that are enjoyable and make
you happy,

Initial Day 1 Interventions Rationale Expected Response

Be Specific to include FITT principles. (What impairment or goal indicates (What movement test will you
(Manual therapy, exercise, education, this treatment is important?) reassess to prove that your treatment
modalities, assistive device, etc.) was effective?)

Manual Interventions: Symptom modulation, movement, Pain/symptom level, Flex and Abd.
1. GH caudal glides, distraction, joint mobility, RC inhibition Pain free ROM
AP (hamburger) soft
tissue/gentle range of motion
2. 2 x 15 sec. 30 sec. rest break
between sets (soft
tissue/gentle ROM)

3. AAROM: Flexion, ABD.,
ER/IR (supine: dowel rod)
4. 2 x 15 each direction; slow
and controlled in and out of
motion
5. Shoulder pendulums
6. 4 sets of 15 seconds; would
be advised to do these as
needed throughout the day
and week in order to reduce
symptoms.
Use of the dowel rod allows her left Pain/symptom level, ROM, overhead
hand and arm to control the ROM and reaching
is there to help as needed. This
combined with her laying on her back
is a great way to stabilize everything
and reduce her risk of moving
awkwardly and out of the plane of
motion. The shoulder pendulums
provide some movement within the
joint and helps reduce pain and
symptoms. This exercise will be good
for her to perform throughout the day
to help manage her shoulder
symptoms.

7. Isometric shoulder flexion,
abd., ER, IR (short of pain
and symptoms)
8. 2 sets of 6 (1 sec. ramp up –
8 sec. hold – 1 sec. ramp
down)
This allows us to load the tendons MMT, overhead reaching
and strengthen the muscle without
asking the muscle to shorten through
its ROM. This allows us to strengthen
and also provides some pain
reduction. Folded towel up against the
wall with all of the motions.

Patient Education/HEP This patient has a lot of psychosocial Functional movement, pain/symptom
9. Traffic light for pain, activity factors that will affect her healing, so level
modification at home, proper education on diagnosis and
 soreness vs. pain, 24 hour
symptoms, prognosis, sleep
10. HEP: walking program,
pendulums for throughout the
day, regimented AAROM with
dowel rod and isometric
strengthening.
prognosis can hopefully mitigate
some of those factors. Creating a
comprehensive HEP will allow us to
limit the number of times she has to
come into the clinic, but it also allows
us to give her a long term
management program.

Assume good patient adherence and no red flags are present. At the next visit, what treatment will you
consider if the patient is:

Better: Worse: The Same:

Increase ROM with AAROM;
introduce pulleys or wall slides if
appropriate.
Change the range at which the
isometrics are done and assess
tolerance
Start to decrease manual
interventions
Incorporate thoracic mobility/scapular
strengthening (if needed through
examination)
In this case, I would ask her about
any changes recently in her activity
levels or life. I would ask about how
she is sleeping and what position she
is sleeping in. I would have her show
me her HEP so I know she is
completing them correctly and ask her
when she is doing her exercises. I
would have to re-educate her on the
importance of activity modification,
sleep position changes, stress/life
management, and how to properly do
her exercises.
Able to tolerate addition of exercises
into daily activity and things are not
worse which is a good sign. I would
continue to progress with the plan I
had in mind with this patient, but
would make sure I am still asking her
to track her symptoms. I would try and
build up her confidence and use this
as a win for her. I would explain how
adding more activity in her life without
things getting worse is a good thing
and that we are on the right track.

Part 7: Course of Physical Therapy Care

Describe the desired end-state or discharge from physical therapy care (what do they look like/what are
they able to do? Consider how that relates to the chief complaint, impairments, and goals.)

For this patient, I would discharge her with a long-term management program in place. This would consist of
resources she can use to help with mental health and life stresses to help improve her overall health and
quality of life. It would also include her HEP with exercises that she can continue to do or use when she has
a symptom flare up which I believe is inevitable with her. I would also make sure there are 2-3 visits available
for her that way if she needs to come back in for a flare up that she can’t personally manage occurs or to
have to asses how things are going post-PT. I expect that she will leave the clinic having completing all of
her goals and have her confident in her ability to use, move, and manage her shoulder.
Describe a treatment plan that will achieve the desired end state/ discharge: Describe how and what you will
re-assess throughout the course of PT care. Explain how your management plan will progress and what
different impairments or areas/regions you will address at future follow-ups.

Treatment Plan: joint mobility, ROM, strengthening, functional activities, patient education, HEP
ROM would be the first area I want to improve because we want to be able to strengthen through the
patients full ROM and if they don’t have functional ROM then we can’t strengthen the muscles through
isotonic contractions. Strengthening exercises would be progressed from isometrics to isotonics with a focus
on gentle concentric and eccentric contractions. We would use CKC, dumbells, and resistance bands
primarily during this phase. Once the patient has demonstrated sufficient strength we would then progress
the exercises to more functional strengthening. This is where lift and carries, overhead reaching, and other
functional activities are introduced. This is where I would be comfortable with loading the patient to
appropriately meet the demands of the activity they want to get back too.

Overhead reaching, shoulder ROM, and shoulder MMT should be reassessed frequently in order to asses
progress with current POC and home program. Once the patient is able to demonstrate equal, pain free
shoulder ROM and strength then we will have to move toward more functional strength testing to quantify
strength and progress.

I would look at thoracic and cervical mobility and seeing if a lack of motion in these areas is causing
abnormal biomechanics at the shoulder. This may include implementing joint mobilizations or exercises that
promote movement through the spine to help position the shoulder in an advantageous position so she is
able to better reach overhead and perform activities with a decrease in pain and symptoms. I think it would
also be a good idea to look at periscapular musculature to see if these muscles are activating and
coordinating correctly to position the scapula so the humeral head has optimal contact and movement at the
glenoid. There may also be some strength deficits that causing dyskinesis of the scapula or causing it to drift
out of position, further causing more issues at the shoulder. Serratus anterior, LT, MT, and rhomboids are
specific muscles I would assess and look at.

What changes to your management plan will you make if they are not progressing as expected? Why?

Intensity, reps, load, and sets would be the first thing I would adjust with my exercises. Maybe the patient is
doing too many reps at the moment or doing the exercise too often. Excessive load can also be a problem.
In order to best address this, a conversation with the patient about what they are having problems with is
very important. Having the patient demonstrate the exercises so you can educate, advise, or fix any
problems you see with the exercise will be helpful in actually seeing and adjusting to the problem. We may
have to regress or progress the exercises depending on patient response. If something is too complex and
hard for the patient to do then it may be smart to break it down into its components that way they can work
on each part. If something is too easy or the patient is beyond the level of the exercise then it may be
beneficial to progress the exercise and add some complexity to it to challenge the patient. More education on
management and prognosis may be needed especially since she has a lot of psychosocial factors involved.
Going over resources to help manage symptoms and just going back over prognosis helps put some
perspective with where they are at in their rehab.